Grievance Redressal Guidelines - PMJAY · manner, NHA has developed Grievance Redressal Guidelines...

Grievance Redressal Guidelines

AYUSHMAN BHARAT - PRADHAN MANTRI JAN AROGYA YOJANA (AB PMJAY)

January 2019

GRIEVANCE REDRESSAL SYSTEM

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CONTENTS

ABBREVIATIONS AND ACRONYMS ........................................................................................................3

1. INTRODUCTION .................................................................................................................................4

2. DEFINITIONS ......................................................................................................................................4

3. OBJECTIVES OF THE GRIEVANCE REDRESSAL SYSTEM ........................................................5

4. GRIEVANCE TYPES AND WHO CAN FILE GRIEVANCES ..........................................................5

5. GRIEVANCE REDRESSAL STRUCTURE AND AUTHORITIES ...................................................6

5.1 DISTRICT GRIEVANCE REDRESSAL COMMITTEE ....................................................................................... 6 5.2 STATE GRIEVANCE REDRESSAL COMMITTEE ............................................................................................ 7 5.3 NATIONAL GRIEVANCE REDRESSAL COMMITTEE ................................................................................. 8

6. MEETING SCHEDULE OF COMMITTEES .....................................................................................9

7. GRIEVANCE REDRESSAL MATRIX ................................................................................................9

8. LODGING AND REGISTRATION OF GRIEVANCES ................................................................... 13

9. GRIEVANCE REDRESSAL MECHANISMS ................................................................................... 14

9.1 DETERMINING THE MODE OF REDRESSAL ............................................................................................ 14 9.2 REDRESSAL THROUGH DIRECT CHANNEL ............................................................................................ 14 9.3 REDRESSAL THROUGH THE RELEVANT GRIEVANCE COMMITTEE...................................................... 15

10. COMPLIANCE WITH ORDERS OF GRIEVANCE REDRESSAL COMMITTEES ..................... 17

11. MODE OF COMMUNICATION ....................................................................................................... 17

12. REPORTING ...................................................................................................................................... 17

13. MONITORING ................................................................................................................................... 18


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Abbreviations and Acronyms

AB PMJAY Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

ATA Action Taking Authority

CGRMS Central Grievance Redressal Management System

CMO Chief Medical Officer

DGNO District Grievance Nodal Officer

DGRC District Grievance Redressal Committee

GOI Government of India

GR Grievance Redressal

GRC Grievance Redressal Committee

ISA Implementation Support Agency

MOHFW Ministry of Health and Family Welfare

NGNO National Grievance Nodal Officer

NGRC National Grievance Redressal Committee

NHA National Health Agency

SGNO State Grievance Nodal Officer

SGRC State Grievance Redressal Committee

SHA State Health Agency

TPA Third Party Administrators


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1. INTRODUCTION

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojna is a flagship program of the

Government which provides a cover up to Rs.5 lakh per family per year for secondary and

tertiary care hospitalization to over 10.74 crore entitled beneficiary families listed as per SECC

2011. The benefits are available free of cost at an empanelled public or private hospital in

cashless and paperless manner, portable across India.

National Health Agency (NHA) is the Nodal Authority set up for Scheme implementation and

oversight. To ensure that disputes and grievances of AB PMJAY beneficiaries, healthcare

providers and other stakeholders are resolved in an efficient, transparent and time bound

manner, NHA has developed Grievance Redressal Guidelines and has established a Central

Grievance Redressal Management System (CGRMS). NHA has the sole prerogative for

subsequent amendments to Guidelines.

2. DEFINITIONS

AB PMJAY Beneficiary refers to all beneficiaries entitled to receive benefits under AB

PMJAY

Action Taking Authority or the ATA Any authority, which may include an individual or an

organization, that has the mandate and the responsibility under AB PMJAY to take action on

the subject matter of the grievance filed by any aggrieved party

Appellate Authority shall mean the State Grievance redressal Committee (SGRC) or the

National Grievance Redressal Committee (NGRC) as the case may be that has the authority

to accept, hear and adjudicate on appeals against the relevant GRC orders.

Central Grievance Redressal Management System or the CGRMS refers to system set by

the National Health Agency for registering, processing, managing and monitoring redressing

all grievances under the AB PMJAY.

Direct Channel refers to the mode of grievance redressal where the concerned District

Grievance Nodal Officer (DGNO) or the State Grievance Nodal Officer (SGNO) redresses

the grievance by directly getting in touch with the concerned stakeholders and / or the Action

Taking authority (ATA) without having to route the matter through one of the Grievance

Redressal Committees (GRC).

Empanelled Health Care Provider refers to all public or private health care providers that

have been empanelled by any State Health Agency (SHA) in the country or by any Insurance

Company on behalf of a SHA for providing cashless hospitalisation benefits under the AB

PMJAY.


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GRC Channel refers to the mode of grievance redressal where the grievance is redressed by

one of the Grievance Redressal Committees (GRC) set up under the AB PM-JAY.

Grievance: A Grievance/complaint refers to any communication that expresses

dissatisfaction about an action or lack of action, about unfair/wrongful treatment, about the

standard of service/deficiency of service that may violate any norms, provisions or

guidelines laid down for AB PMJAY or asks for remedial action.

Grievance Redressal means the mechanisms for receiving, registering and addressing

grievances received from any of the aggrieved stakeholder.

Grievance Redressal Committee (GRC) refers to committees set up by the SHA or the NHA

for redressing all stakeholder grievances under the AB PMJAY.

3. OBJECTIVES OF THE GRIEVANCE REDRESSAL SYSTEM

To ensure that grievances of all stakeholders are redressed within the time frames prescribed

in the GR Guidelines up to the satisfaction of the aggrieved party based on the principles of

natural justice while ensuring that cashless access to timely and quality care to remains

uncompromised.

4. GRIEVANCE TYPES AND WHO CAN FILE GRIEVANCES

4.1 Grievances can be filed by any party directly or indirectly involved with the AB PMJAY

or any stakeholder

For this purpose, a stakeholder includes:

i. AB PMJAY Beneficiary;

ii. Healthcare Provider

iii. Insurer or its employees;

iv. Implementation Support Agency (ISA) or its employees

v. State Health Agency (SHA) or its employees or nominated functionaries for

implementation of the Scheme; and

vi. Any other person having an interest or participating in the implementation of the

Scheme.

4.2 Any person, who is not a beneficiary of PM-JAY and is not acting on behalf of a AB-

PMJAY beneficiary and who may have observations, comments, feedback on any aspect

of the Scheme, shall resort to other channels of feedback and not use the provisions of the

GRMS.

4.3 Illustrative and indicative list of grievances is given in the Grievance Redressal Matrix

(refer to Table 1 in this document).


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5. GRIEVANCE REDRESSAL STRUCTURE AND AUTHORITIES

AB PMJAY has a three-tier grievance redressal structure to ensure timely redressal of

grievances. This section of the guidelines lays down these structures, their constitution and

functions.

5.1 District Grievance Redressal Committee

5.1.1 A District Grievance Redressal Committee (DGRC) will be constituted by the SHA

in each district as per the following schedule:

a. For insurance mode: Within 15 days of the SHA signing of MoU with the

Insurance Company.

b. For assurance mode: Within 15 days of the SHA signing of MoU with the

Central Government.

5.1.2 Constitution of the DGRC:

a. Head of the District or District Magistrate or District Collector or Deputy

Commissioner shall be the Chairperson of the DGRC

b. The Chief Medical Officer of the district shall be the Convener.

c. Representative of Rural Development Department of the state government.

d. District Coordinator of the Insurer (in case of insurance mode)

e. District Grievance Nodal Officer (DGNO)

f. Other experts for specific cases as determined by the Chairperson or the Convenor on

behalf of the Chairperson.

5.1.3 Functions of the DGRC:

The DGRC shall perform all functions related to handling and resolution of grievances

within their respective districts. The specific functions will include:

a. Track and redress all grievances referred to it, following the principles of natural

justice.

b. Call for additional information as required either directly from an aggrieved party

or from the concerned agencies / individuals.

c. Conduct grievance redressal proceedings as required.

d. If required, call for hearings and representations from the parties concerned while

determining the merits and demerits of a case.

e. Adjudicate and issue final orders on grievances.

f. In case of grievances that need urgent redressal, develop internal mechanisms for

redressing the grievances within the shortest possible time, which could include,

but not be limited to, convening special meetings of the DGRC.

g. Review grievance records.

h. Monitor the grievance database to ensure that all grievances are resolved within 30

days or earlier stated as per the provisions of these guidelines or any amendments

to the GRMS Guidelines issued by the NHA and / or the SHA.


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5.2 State Grievance Redressal Committee

5.2.1 The State Grievance Redressal Committee (SGRC) will be constituted by the SHA

within 15 days of the SHA signing the MoU with the Central Government.

5.2.2 Constitution of the SGRC:

a. CEO of SHA / State Nodal Agency (SNA) shall be the Chairperson of the

SGRC.

b. The State Grievance Nodal Officer (SGNO) of the SHA shall be the Convenor

of SGRC.

c. Representatives of the Departments of Rural Development, Women & Child

Development, Labour, Tribal Welfare.

d. Director Health Services.

e. Medical Superintendent of the leading state level government hospital or the

Dean of the leading medical college in the State.

f. Representative of Insurance Company (Applicable only where scheme is in

Insurance Mode)

g. Other experts for specific cases as determined by the Chairperson or the

Convenor on behalf of the Chairperson.

Note: In case of any grievance between SHA and Insurance Company or the SHA and

an EHCP, the appellete authority will be the Principal Secretary of Department of

Health & Family Welfare.

5.2.3 Functions of the SGRC:

The SGRC shall perform all functions related to handling and resolution of all

grievances received either directly or escalated through the DGRC. When beneficiary

is the one of the party the decision of the SGRC will be final. The specific functions

will include:

a. Act as an Appellate Authority for appealing against the orders of the DGRC.

b. Track and redress all grievances referred to it, following the principles of

natural justice.

c. Call for additional information as required either directly from an aggrieved

party or from the concerned agencies / individuals.

d. Conduct grievance redressal proceedings as required.

e. Nominate District Grievance Nodal Officer (DGNO) at each District.

f. Oversee grievance redressal functions of the DGRC including but not limited

to monitoring the turnaround time for grievance redressal.

g. Perform all tasks necessary to decide on all such appeals within 30 days of

receiving such appeal.

h. Adjudicate and issue final orders on grievances.

i. Ensure compliance to the GRMS Guidelines


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5.2.4 For any appeal escalated to the SHA, the SHA may at its sole discretion assign the

task of investigation of the grievance to the independent agency or relevant official if

need be.

5.3 National Grievance Redressal Committee

5.3.1 The National Grievance Redressal Committee (NGRC) shall be formed by the

National Health Agency at the national level.

5.3.2 Constitution of the NGRC:

a. The constitution of the NGRC shall be determined by the NHA in accordance with the

GR Guidelines from time to time.

b. Proposed members for NGRC are:

i. Deputy CEO of National Health Agency (NHA) - Chairperson

ii. Executive Director, Monitoring and Evaluations & operations (NHA) –

Convenor

iii. General Manager, Operations- Member

iv. Other experts for specific cases as determined by the Chairperson or the

Convenor on behalf of the Chairperson.

5.3.3 Functions of the NGRC:

a. The NGRC shall act as the final Appellate Authority at the national level.

b. The NGRC shall only accept appeals and petitions against the orders of the

SGRC of a State. The decision of NGRC will be final.

c. Review state-wise performance of the GRMS. Review may include but not be

limited to analysis of monthly reports from the SHA and field visits for

monitoring, evaluation and make suggestions for improvement in the system.

d. Provide need-based mentoring and capacity building support to the SGRCs.

e. Any other reference on which report of NGRC is specifically sought by any

Competent Authority.

f. Issue specific recommendations to the states for corrective actions and process

improvement based on state-wise review of grievance redressal data.

g. Issue amendments to the national grievance redressal guidelines as and when

required.

5.3.4 The meetings of the NGRC will be convened as per the cases received with it for

consideration or as per the convenience of the Chairman, NGRC.

5.3.5 For any appeal escalated to the NHA, the NHA may at its sole discretion assign the

task of investigation of the grievance to the independent agency or relevant official if

need be.

5.4 Grievance Officer

5.4.1 District Grievance Nodal Officer (DGNO)


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DGNO is a person who is nominated by SGRC to resolve the grievances at district

level under PM-JAY. The roles and responsibilities of DGNO are as listed below

a. Addressing grievances of stakeholders directly or through DGRC within the

timeframe defined.

b. Ratifying the actions taken against the grievances by placing in the DGRC from

time to time

c. Enter the particulars of the grievance on the CGRMS portal received directly,

telephonically, through letter, email or social media and updating the status in

CGRMS.

d. Referring grievances to convener of DGRC

e. Submitting reports and records

5.4.2 State Grievance Nodal Officer (SGNO)

SGNO is a person who is nominated by SHA to address the grievances at state level

under PM-JAY. The roles and responsibilities of the SGNO are as listed below

a. Addressing grievances of stakeholders directly or through SGRC within the

timeframe defined.

b. Ratifying the actions taken against the grievances by placing them in the SGRC

from time to time

c. Forwarding the grievances which are received at state level to concerned DGNO

for further actions

d. Referring grievances to convener of SGRC

e. Submitting reports and records

5.4.3 National Grievance Nodal Officer

NGNO is a person who is nominated by NHA to address the grievances at National

level under PM-JAY. The roles and responsibilities of the NGNO are as listed below

a. Forwarding the grievances received at national level to concerned SGNO for

further actions

b. Referring grievances to convener of NGRC

c. Monitoring of the grievances and ensuring grievances are resolved as per the time

frame

d. Submitting reports and records

6. Meeting Schedule of Committees

The DGRC & SGRC meeting should be conducted every month on a specific day regularly.

State can decide a particular date based on the convenience and availability of the members

of the committee.

7. GRIEVANCE REDRESSAL MATRIX

7.1 Grievances under the AB PMJAY shall be redressed as per the matrix presented in Table

1 below:

Table 1: AB PMJAY Grievance Redressal Matrix

Aggrieved

party

Grievance

against Indicative nature of grievances

Approach

authority

Turn- around

time

Grievance escalated to

Committees (if either party is

not satisfied)

Beneficiary

Empanelled

Healthcare

providers

• Denied treatment under PMJAY by

empanelled healthcare provider at

the time of admission

• Demanding extra money for the

packages covered under the scheme

(Grievances registered before

discharge)

• Not returning PMJAY card at the

time of discharge

DGNO 48 hours

If not resolved in 48 hours by

DGNO, case shall be referred to

DGRC

Beneficiary

Empanelled

Healthcare

providers

• Denied treatment under PMJAY

(grievance registered at the time

of discharge or after discharge)

• Demanding extra money for the

packages covered under the scheme

(grievance registered after

discharge)

DGNO 15 days DGRC (Within 30 days of the

DGNO decision)

Beneficiary Insurance

company / • Denied treatment

DGNO /

DGRC

15 days of

receipt of

• If grievance is not resolved

by DGNO within 15 days,


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TPA/hospital/any

functionary of

PM-JAY

• Money sought for treatment, despite Sum

Insured under PMJAY Cover being

available

• Demanding more than Package Rate/

Pre-Authorized Amount, if Sum Insured

under PM-JAY Cover is insufficient or

exhausted

• PMJAY eCard retained by Empaneled

Health Care Provider

• Medicines not provided against OPD

Benefits or follow-up care

• Ecard not provided despite eligibility

grievance for

DGNO

30 days of

receipt of

grievance for

DGRC

case shall be referred to

DGRC.

• If either party is not

satisfied with DGNO’s

decision, then they can

appeal to DGRC within 30

days of the DGNO order

• DGRC shall have 30 days

to resolve the grievance.

• If either party is not

satisfied with DGRC

decision, then they can

appeal to SGRC within 30

days

• SGRC shall have 30 days

to resolve the grievance.

• SGRC decision will be

final

Beneficiary District

authorities

• Grievance not addressed by the

concerned officer SGNO /

SGRC

30 days of

receipt of

grievance

Decision of the SGRC on such

cases shall be final and binding.

Health Care

Provider

Beneficiary /

Insurance

Company / ISA /

TPA / any

functionary /

SHA

• Claims rejected by Insurer or full Claim

amount not paid

• Suspension or de-empanelment of

Empaneled Health Care Provider

• Hospital IT Infrastructure not

functioning, Insurer/ISA not assisting in

solving issue or not accepting manual

transaction

• Not received claims reimbursement in

time

DGNO /

DGRC

15 days of

receipt of

grievance

- If grievance is not resolved by

DGNO within 15 days, case

shall be referred to DGRC.

- If either party is not satisfied

with DGNO’s decision, then

they can appeal to DGRC

within 30 days of the DGNO

order


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- DGRC shall have 30 days to

resolve the grievance.


with DGRC decision, then they

can appeal to SGRC within 30

days

-

- SGRC shall have 30 days to

resolve the grievance


with SGRC order, they may

approach the NGRC within 30

days of the SGRC order.

- Decision of the NGRC shall be

final and binding.

Insurance

Company /

ISA / TPA

District

Authorities /

Health Care

Providers / SHA

• Premium not received within time

prescribed

• AB-PMJAY Beneficiary Database not

updated

SGNO /

SGRC

30 days of

receipt of

grievance

- NGRC (within 30 days of the

SGRC decision)

- NGRC shall decide within 30

days of the receipt of appeal.

- Decision of the NGRC shall be

final and binding.


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7.2 Beneficiary grievances related to eligibility, hospitalisation, denial of services or demand

for any out-of-pocket payment by the empanelled provider or any of its or agents shall be

resolved within 48 hours of receipt of the complaint / appeal.

7.3 For inter-state / Union Territory (Portability) cases:

a. All beneficiaries’ grievances against the hospital shall be referred to the DGNO of

the State/UT where beneficiary is applying/availing benefits of PM-JAY (other than

parent State/UT)

b. Inter-state beneficiary cases should be solved by concerned DGRC and SGRC. The

SGRCs of both the states shall coordinate between themselves, if required, to

amicably redress the grievance.

c. All Empanelled Health Care Provider grievances against the Insurer / SHA shall be

referred to the SGRC of both parent State/UT and State/UT where the claim is

raised State/UT. The SGRCs of both the states shall coordinate between them, if

required, to amicably redress the grievance.

8. LODGING AND REGISTRATION OF GRIEVANCES

8.1 If any stakeholder has a grievance (aggrieved party) against any stakeholder of AB

PMJAY as set forth in Table 1, she / he may lodge a grievance through one of the following

means:

Online Mode

• Through online grievance redressal portal – CGRMS of AB PMJAY

(https://cgrms.pmjay.gov.in/)

Offline Mode

• AB PMJAY Call center helpline operated by the State/ NHA.

• Through letter, telephone, e-mail, and fax to the official addresses of the SHA or the

NHA

• Directly with the DGNO of the district where such stakeholder is located or where such

grievance has arisen

• DGNO shall enter the particulars of grievances received via offline mode in the portal.

8.2 For all grievances received by the call center, call center executives shall register the

details of the grievance in the CGRMS defined format and forward the same to DGNO or

State Grievance Nodal Officer of the State concerned in case DGNO details are not

updated. SGNO shall allocate the same to the concerned District.

https://cgrms.pmjay.gov.in/


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8.3 All grievances, irrespective of the means through which it is lodged, shall be forwarded to

the concerned DGNO with a copy to the SGNO.

8.4 The DGNO shall enter the particulars of the grievance on the CGRMS portal established

by the NHA.

8.5 The CGRMS will automatically: (i) generate a Unique Ticket Number (UTN); (ii)

categorize the nature of the grievance; and (iii) an e-mail / letter / SMS to be sent to the

appropriate stakeholder to which such category of grievance is to be referred (including

updating on phone) as per the Grievance Redressal Matrix (Table 1).

8.6 Special powers of the authorities: The SHA, SGRC and/ or the NHA shall have the

authority to initiate suo moto proceedings and file a grievance on behalf of itself and / or

PM-JAY Beneficiaries under the Scheme. They can also take cognizance of reports in

social media and other public forums for further investigation and redressal.

9. GRIEVANCE REDRESSAL MECHANISMS

9.1 Determining the mode of redressal

9.1.1 Upon a grievance being received by the DGNO, the DGNO shall decide whether:

a. the substance of the grievance is a matter that can be directly addressed by the

stakeholder against whom the grievance is lodged or an Action Taking

Authority (ATA) (‘Direct Channel’); or

b. whether such matter requires to be dealt with through the grievance redressal

committees (‘Grievance Redressal Committee Channel’ – GRC Channel).

9.1.2 To the extent possible, the DGNO shall exercise its authorities to ensure that

grievances are redressed through the Direct Channel.

9.1.3 If the DGNO decides that the grievance must be dealt with under the GRC channel,

the DGNO shall refer such grievance to the Convener of the relevant Grievance

Redressal Committee.

9.2 Redressal through Direct Channel

If the DGNO decides that the grievance need not be dealt with under the grievance redressal

mechanism and opts for the Direct Channel, then the following procedures shall be

followed:


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9.2.1 Once the UTN is generated, the DGNO shall send or cause to be sent an

acknowledgement email / SMS / phone call to an aggrieved party and provide an

aggrieved party with the UTN. Upon receipt of the UTN, an aggrieved party will have

the ability to track the progress of grievance resolution online through CGRMS and

use the same at the time of calling the helpline for allowing easy retrieval of the

specific grievance data.

9.2.2 The stakeholder against whom a grievance has been lodged must send its comments/

response to an aggrieved party and copy to the DGNO within 15 days. If the

grievance is not addressed within such 15-day period, the DGNO shall send a reminder

to such stakeholder(s) for redressal within a time period specified by the DGNO.

9.2.3 The DGNO shall try to resolve the grievance by forwarding the same to Action Taking

Authority (ATA). If the grievance is not resolved or comments are not received over

the same within 15 days of the grievance, then the matter may be referred to DGRC.

9.2.4 If the DGNO is satisfied that the comments/ response received from the stakeholder

satisfactorily addresses the grievance(s), then the DGNO shall communicate this to an

aggrieved party by e-mail / SMS and phone and update the CGRMS.

9.2.5 If the DGNO is not satisfied with the comments/ response received or if no comment/

response is received from the stakeholder despite a reminder, then the DGNO shall

refer such grievance to the Convener of the relevant Grievance Redressal Committee

depending on the nature of the grievance after which the procedures set out shall

apply.

9.3 Redressal through the Relevant Grievance Committee

9.3.1 The DGNO shall update the CGRMS, categorize the grievance and automatically refer

it to the Convener of the relevant Grievance Redressal Committee by way of e-mail.

9.3.2 The Convener of the relevant Grievance Redressal Committee shall place the

grievance before the Grievance Redressal Committee for its decision at its next

meeting.

9.3.3 Each grievance shall be addressed by the relevant Grievance Redressal Committee

within a period of 30 days of the receipt of the grievance. For this purpose, each

Grievance Redressal Committee shall be convened at least once every 30 days to

ensure that all grievances are addressed within this time frame. Depending on the

urgency of the case, the Grievance Redressal Committee may decide to meet earlier

for a speedier resolution of the grievance.

9.3.4 The relevant Grievance Redressal Committee shall arrive at a reasoned decision

within 30 days of receipt of the grievance. All such decisions shall be based on the


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principles of natural justice (including giving the parties a reasonable opportunity to

be heard) and be taken by majority vote of its members present.

9.3.5 If any party to a grievance is not satisfied with the decision of the relevant Grievance

Redressal Committee, it may appeal against the decision within 30 days to the relevant

Grievance Redressal Committee or other authority having powers of appeal as set

forth in Table 1.

9.3.6 If an appeal is not filed within 30-day period, the aggrieved party shall lose its right

to appeal and the decision of the original Grievance Redressal Committee shall be

final and binding.

9.3.7 A Grievance Redressal Committee or other authority having powers of appeal shall

dispose of an appeal within 30 days of receipt of the appeal. The decision of the

Grievance Redressal Committee or other authority with powers of appeal shall be

taken by majority vote of its members. Such decision shall be given after following

the principles of natural justice, including giving the parties a reasonable opportunity

to be heard. The decision of the Grievance Redressal Committee or other authority

having powers of appeal shall be final and binding.

The grievance redressal mechanism is presented in the flow chart in the figure below. If there

are any inconsistencies in the flow chart and the provisions of Section 8 of these GRMS

Guidelines, the latter shall prevail.

Figure 1: Grievance Redressal Mechanism Flowchart


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10. COMPLIANCE WITH ORDERS OF GRIEVANCE REDRESSAL COMMITTEES

10.1 Parties against whom an order has been issued by any GRC, shall ensure that all orders are

fully complied with and executed within not more than 30 calendar of the issuance of the

order unless such order has been stayed on appeal.

10.2 If the party against whom such orders have been issued, fails to comply with the order

within 30-day period or a time period set forth in the GRC Order, the defaulting party shall

be liable to pay penalty as described under the contract between the parties or penalty of

Rs. 25,000 per month for the first month or part thereof of such non-compliance and Rs.

50,000 per month or part thereof thereafter until the order of such GRC is complied with.

The defaulting party shall be liable to pay such penalty to the SHA within 15 days of

receiving a written notice from the SHA. All such payments have be made by the

defaulting party in the manner specified by the SHA in such a notice. However, if the

SHA is the defaulting party, such notices shall be issued by the NHA and the penal interest

shall be paid by the SHA to the NHA.

10.3 On failure to pay such penalty, the defaulting party shall be liable to pay a penal interest

at the rate of one percent of the total outstanding penalty amount for every 15 days for

which such penalty amount remains unpaid.

10.4 For delays in compliance to the order beyond three months of the date of its issue, the SHA

/ NHA shall have the right to seek recourse to available legal remedies all costs of which

shall be borne by the defaulting party.

11. Mode of Communication

The decision made by the grievance officer or the grievance committee must be

communicated to the parties within 3 days through any of the below channels

In case of beneficiary- he/she should be informed through 1. Letters or 2. Emails 3. SMS- About the status 4. Outbound call from call centre (Should be recorded and saved)

In case of Hospitals/Insurance Company/ISA 1. Letters 2. Emails

12. REPORTING

12.1 The SGRC shall, through the SHA, submit monthly status reports of the grievance

redressal management system to the NGRC.

12.2 All such reports shall be in the form and manner prescribed by the NHA from time to time.


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13. MONITORING

13.1 The SHA shall be responsible for monitoring the functioning of the GRMS within the state.

13.2 Some of the key indicators for tracking the efficiency of the GRS system shall be:

Table 2: Resolution turn-around time ratio

Indicator Resolution turn-around time ratio

Description Share of grievances that are resolved within the prescribed

time frame

Numerator (N) Number of grievances resolved within the prescribed time

Denominator (D) Total number of grievances registered

Calculation N * 100 / D

Frequency of

measurement Monthly

Acceptable Threshold 98 percent or more

Table 3: Escalation ratio

Indicator Escalation ratio

Description Share of grievances that needed escalation

Numerator (N) Number of GRC orders that were appealed against

Denominator (D) Total number of GRC orders issued


Frequency of measurement Monthly

Acceptable Threshold 10 percent or less

Table 4: Grievance registration efficiency ratio

Indicator Grievance registration efficiency ratio


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Description Share of grievances forwarded by the NHA that were registered

in the CGRMS within 24 hours.

Numerator (N)

Number of grievances forwarded by the NHA that were not

registered by the SGNO / DGNO within the prescribed time

frame

Denominator (D) Total number of grievances forwarded by the NHA to the SGNO

/ DGNO


Frequency of

measurement Monthly

Acceptable

Threshold 1 percent or less

13.3 The NHA shall provide overall supervision and monitoring of the implementation of the

GRMS across all states. This may include site visits, and internal and third-party process

audits.

13.4 These indicators are illustrative and may evolve and be amended by the NHA and / or the

SHA from time to time.

13.5 Monitoring of time series grievance data may also provide insights into the overall

performance of the AB PMJAY. Some of these indicators could be:

a. Number of grievances resolved through Direct Channel

b. Number of beneficiary grievances related to out-of-pocket payments

c. Number of beneficiary grievances related to quality of services

d. Number of beneficiary grievances related to denial of services

e. Number of beneficiary grievances related to delays in receiving services

f. Number of grievances from empanelled providers related to partially or fully

rejected claims

g. Number of grievances from empanelled providers related to delays in receiving

claims reimbursements

h. Number of beneficiary grievances related to portability benefits

i. Number of provider grievances related to portability claims

13.6 Analyses of these grievance related indicators over time and across states (may be even

across districts) is likely to provide useful insights for course corrections and strengthening

the implementation mechanisms under the AB PMJAY.

*****

Date post:	22-Jun-2020
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Grievance Redressal Guidelines - PMJAY · manner, NHA has developed Grievance Redressal Guidelines...

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